The deal forms a new nonprofit entity called the CommonWell Health Alliance, which strives to create standards to promote data liquidity between the competing EHR systems. The standards will allow for the sharing of data at the direction of the patient; that adds a consent and governance layer to CommonWell's efforts, on top of an identification component similar to a national patient identifier. Both patient identifiers and permission for information access have been elusive pieces of health information exchange, or HIE, that create a lack of interoperability between competing EHRs.

The CEOs of all five companies gathered at a press conference to unveil CommonWell at HIMSS 2013. This year, the organization will concentrate on proof of concept and making CommonWell work; next year, it will formally launch. No specific interoperability standards have been released yet.

"We believe that one of the key challenges we face is not just automating health care but connecting it together," said McKesson CEO John Hammergren. "Over time we've done a good job, I think, as an industry, of automating our silos. But we've not done a very good job of collaborating across the silos and developing the connectivity that's going to be necessary to make it happen."

Cerner CEO Neal Patterson said that his company and McKesson finalized the deal over the last three weeks, with the other three EHR vendors joining at the end. "We need and want the entire industry to participate in this," he said. "There's a level of complexity here, but it's a level of complexity that's doable today."

Allscripts CEO Paul Black said the need to join the battle for health data interoperability became "very personal" when his wife was diagnosed with breast cancer and he struggled to help aggregate her data among primary care physicians, oncologists, surgeons and other physicians at various facilities using different EHRs. "They all needed access to [her] information to be able to make critical decisions," he said. "At that moment, they couldn't get access to that information. If CommonWell Health Alliance had been operating, they would have had the ability to be able to retrieve that information."

The alliance, announced during the first day of HIMSS 2013, will take some time to develop. National HIT Coordinator Farzad Mostashari, M.D., reacted happily to the announcement, saying it appeared the free market was at long last beginning to develop a solution to its interoperability problems. On several occasions throughout the last year, he has remarked that if vendors cannot solve patient data interoperability issues on their own, his office could in the future take "a traditional regulatory approach" to make it happen.

"Customers are demanding interoperability, and vendors are responding to the market," Mostashari told SearchHealthIT. "I see this and many other activities going on in the vendor space, and I'm very hopeful, not about any specific effort, but the direction that we're moving. It's one that interoperability is a huge item of interest. It's a huge bar that vendors have to meet to be credible in this space now."

Combined, the five vendors claim 41% of the hospital EHR market and 23% of the ambulatory EHR market, according to the Bipartisan Policy Center, which moderated the CommonWell press announcement.

Anatomy of a deal: CommonWell started with national patient identifier issue

The idea started last year, said David McCallie Jr., M.D., Cerner vice president of medical informatics, in an interview with SearchHealthIT.

Cerner's Patterson had been banging the drum for a national patient identifier for some time. He said during a CommonWell press event that he's given up on trying to figure out why it can't be done at the federal level, or why a law was passed to forbid the ONC or other governmental entities to create it while other Western nations have legislated national health identification systems. But he's accepted the reality, and is ready for Cerner to contribute to a private sector approach.

As McCallie tells it, Mostashari discussed the lack of a national patient identifier system at a May 2012 Bipartisan Policy Center meeting, where a group of assembled EHR vendor reps were among the attendees. "You've got to solve this; I can't," McCallie recalled Mostashari telling them. "He literally said, 'I can't even legally studythis; quit bugging me.'"

There's a tremendous amount of information in health care today, but there's very little liquidity. This is the beginning of that formation of liquid information.

Tee Green, CEO, Greenway Medical Technologies

It occurred to McCallie that health data could move from one system to another better than it does today, if EHR vendors could define standards across their systems that would first, identify patients; second, control consents on behalf of the patients; and third, adhere to a common governance model to link records across care locations.

The problem with today's health data, McCallie said, is that while it's all data, it's just a bit different from vendor to vendor. He likened moving data from one EHR to another to "trying to drop a Ford engine into a Chevy." Sure, they're both trucks and they're both engines, but they aren't interoperable.

McCallie called Arien Malec, vice president of data platform solutions for McKesson, with whom he had worked with to develop Direct health-data messaging open standards for federal committees. They started sketching out a plan for making data exchange work. "We had been thinking about something like this for a little while, internally," Malec told SearchHealthIT. "We started the conversation going, and got our respective CEOs excited and fired up."

Before long, they realized they were about to wade into potential intellectual-property issues, and with upper management's blessing they got attorneys involved, which, Malec acknowledged, slowed down the progress. But getting the legal department involved kept the project moving toward a conclusion agreeable to both companies. "There's a tremendous amount of information in health care today," said Tee Green, Greenway CEO, during the press event. "But there's very little liquidity. This is the beginning of that formation of liquid information. ... [T]hat's what's going to lead us to building a smarter health care system."

Epic Systems not yet included in CommonWell roster

In the press conference, the executives stressed that all EHR vendors are invited to join CommonWell. Noticeably absent from the stage, however, was Judy Faulkner, CEO of Epic Systems Corp., which has made its own efforts toward interoperability within its products.

When asked point-blank whether Faulkner had been approached to join CommonWell -- and if she'd demurred, what was her reason was -- Hammergren said everyone in the industry will be invited eventually, but the companies wanted to make the announcement and didn't feel it necessary to sign up every EHR vendor before doing so. "The fact that we're up here doesn't mean that this is an exclusive group," he said.

What would it take to get Faulkner and Epic to the table? "It's a question of if they want to do it," Hammergren later told SearchHealthIT. "That management team will have to decide that this strategy makes sense for them to participate. We plan to invite everyone; we already invited everyone ... the question now [for Epic] is, does this make sense from a strategy perspective and if their clients -- the patients that they serve -- will be better off."

Carl Dvorak, president of Epic, said his company wasn't invited to join CommonWell, and that he was made aware of it only "at a very high level" recently, without many details. He said he wasn't certain Epic would join the new alliance.

"We support the national standards, we are a supporting member of Healtheway," Dvorak said. "I'm not sure the world needs yet another alliance, especially a commercial alliance, when what we really should do is get behind the national standards and work on making them plug-and-play."

He added that Epic connects with several governmental agencies such as the Veterans Affairs and Defense departments. He also pointed out that Epic's EHR already connects with Greenway's product, and the company is working on a connector with Cerner.

He cited Epic's monthly processing of 708,000 patient care transitions and 3.4 million transactions per month. "About 38% of them are with non-Epic systems, using the national standards for Healtheway."

Reaction mixed on HIMSS 2013 floor

While Mostashari expressed enthusiasm at the direction vendors were taking toward patient data interoperability, some observers at HIMSS 2013 reserved judgment for when they see more specifics. Keith Boone, GE Healthcare standards architect and HL7 board member, who stressed he was speaking for himself and not for GE or HL7, said he's taking a wait-and-see attitude until he gets a deep, technical look under the hood of the standards CommonWell will eventually advocate.

"The last thing I need is one more program to pay attention to," said Boone, who also volunteers his time helping develop open standards for federal committees, including the Automated Blue Button Initiative. "I think this is good if the idea is to keep things moving forward. ... [I]t's hard to say. It's too early."

Popular patient advocate "e-Patient" Dave deBronkart likened health IT's present interoperability dilemmas to the desktop publishing market of the 1980s and 1990s. Then, PageMaker layout and design application software from Aldus Corp. (later, Adobe Systems Inc.) overthrew conventional typesetting, and Quark Inc.'s QuarkXPress overthrew PageMaker. Publishing then, and health IT now, are "going through hell as they computerized," he said in an email to SearchHealthIT. Eventually, he hopes patient data, not vendors, will be the priority; and in his mind, the CommonWell project is the biggest news for patients and families coming out of HIMSS 2013.

"When a massive new pool of data comes into existence, at some point it becomes 'all about the ecosystem,'" deBronkart wrote. "Connectedness can be of more value in the market than the superpowers of any one unconnected component or system."

Intermountain Healthcare CIO Marc Probst said the potential CommonWell-versus-Epic faceoff reminded him of the 1980s VHS-versus-Betamax videocassette format war. One of the patient data formats eventually will become the dominant standard if CommonWell formats gain traction and they battle head-to-head for market share.

But that's only if CommonWell gets off the ground. "It feels like desperation to me," Probst said. "It seems a little reactionary to me. Would these guys have naturally done this?" Of course, for his health care system, the CommonWell announcement doesn't really affect him one way or another; Intermountain created its own EHR.

He does see one silver lining, however. "Anything that drives to standards helps us in what we're trying to accomplish," Probst said. "If this drives us to two [standards], sweet. That's a way-different deal than 30. I'm a real fan of Farzad, and I think his leadership is driving this."